Liberty Park Elementary Counseling Services Parent/Guardian Referral Form (2020-2021)

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A student may be referred to the school counselor by a parent/guardian, staff member or the student may refer themselves. Services provided by the school counselor through this referral process include individual and group counseling as well as informal check ins. Confidentiality is maintained at all times when meeting with the school counselor unless the child gives permission to share information or if the child says they are planning to hurt themselves, someone else or that someone has hurt them. It is the objective that all students will build healthy relationships and be successful at school. This occurs when students, families and the school are working together. School counseling services are available to every student.

Email *

Student Name: *

Grade/Teacher: *

Parent/Guardian Name: *

Telephone Number: *

Email:

Description of Concern: *

Student knowledge of referral: *

Student is aware of the referral.

Referral has not been discussed with student.

Have you discussed concerns with student's teacher? *

Yes

I would like: *

school counselor to call me to discuss.

to schedule a meeting.

counselor to meet with my child as soon as possible - URGENT!

counselor to meet with my child after we first talk.

Required

Is your child currently working with a mental health professional? *

Yes

If they are working with a mental health professional, please indicate the provider:

Gallahue (school based therapy/services)

Other

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